MedSurg HESI Practice

A 24-year-old female client diagnosed with a human papillomavirus infection (HPV) is angry at her ex-boyfriend and says she is not going to tell him that he is infected. Which response is best for the nurse to provide? "You do not have to tell him because this is not a reportable disease." "Because there is no cure for this disease, telling him is of no benefit to him or to you." "Even though you are angry, he should be told, so he can take precautions to prevent the spread of infection."

"Even though you are angry, he should be told, so he can take precautions to prevent the spread of infection."

Which is the primary nursing problem for a client with asymptomatic primary syphilis? -Acute pain. -Risk for injury. -Sexual dysfunction. -Deficient knowledge.

-Deficient knowledge.

Which assessment finding should most concern the nurse who is monitoring a client two hours after a thoracentesis? New onset of coughing. Low resting heart rate. Distended neck veins. Decreased shallow respirations.

New onset of coughing.

A client with sickle cell anemia is admitted with severe abdominal pain and the diagnosis is sickle cell crisis. Which is the most important nursing action to implement? -Limit the client's intake of oral fluids and food. -Evaluate the effectiveness of narcotic analgesics. -Encourage the client to ambulate as tolerated. -Teach the client about the prevention of crises.

-Evaluate the effectiveness of narcotic analgesics.

The nurse is caring for a young adult who is having an oral glucose tolerance test (OGTT). Which laboratory result should the nurse assess as a normal value for the two-hour postprandial result? -140 mg/dL. -160 mg/dL. -180 mg/dL. -200 mg/dL.

-140 mg/dL.

Which client should be further assessed for an ectopic pregnancy? -A 24-year-old with shoulder and lower abdominal quadrant pain. -A 33-year-old with intermittent lower abdominal cramping. -A 20-year-old with fever and right lower abdominal colic. -A 40-year-old with jaundice and right lower abdominal pain.

-A 24-year-old with shoulder and lower abdominal quadrant pain.

The home health nurse is assessing a client with terminal lung cancer who is receiving hospice care. Which activity should be assigned to the (PN)? -Administer medications for pain relief, shortness of breath, and nausea. -Clarify family members' feelings about the meaning of the client's behaviors and symptoms. -Develop a plan of care after assessing the needs of the client and family. -Teach the family to recognize restlessness and grimacing as signs of client discomfort.

-Administer medications for pain relief, shortness of breath, and nausea.

A client who has a chronic cough with blood-tinged sputum returns to the unit after a bronchoscopy. Which nursing interventions should be implemented in the immediate postprocedural period? -Keep the client on bed rest for eight hours. -Check vital signs every 15 minutes for two hours. -Allow the client nothing by mouth until the gag reflex returns. -Encourage fluid intake to promote the elimination of the contrast

-Allow the client nothing by mouth until the gag reflex returns.

The nurse is caring for a client with acute pancreatitis and assesses the admission laboratory results. Which laboratory value should the nurse anticipate being elevated with this diagnosis? -Triglycerides. -Amylase. -Creatinine. -Uric acid.

-Amylase.

A male client with chronic atrial fibrillation and slow ventricular response is scheduled for surgical placement of a permanent pacemaker. How should the nurse explain the action of a synchronous pacemaker? -Ventricular irritability is prevented by the constant rate setting of the pacemaker. -An impulse is fired every second to maintain a heart rate of 60 beats per minute. -An electrical stimulus is discharged when no ventricular response is sensed.

-An electrical stimulus is discharged when no ventricular response is sensed.

The PET (positron emission tomography) scan is commonly used with oncology clients to provide for which diagnostic information? -A description of inflammation, infection, and tumors. -Continuous visualization of intracranial neoplasms. -Imaging of tumors without exposure to radiation. -An image that describes metastatic sites of cancer.

-An image that describes metastatic sites of cancer.

A client with a chronic infection of Hepatitis C virus (HCV) is scheduled for a liver biopsy. Which intervention should the nurse perform after the procedure? -Progress activity as soon as possible. -Assess for signs of bleeding and hypovolemia. -Place the client in the left lateral position. -Monitor blood pressure, pulse and breathing every 4 hours.

-Assess for signs of bleeding and hypovolemia.

A client who had abdominal surgery two days ago has prescriptions for intravenous morphine sulfate 4 mg every 2 hours and a clear liquid diet. The client complains of feeling distended and has sharp, cramping gas pains. Which nursing intervention should be implemented? -Obtain a prescription for a laxative. -Withhold all oral fluid and food. -Assist the client to ambulate in the hall. -Administer the prescribed morphine sulfate.

-Assist the client to ambulate in the hall.

Which instruction should the nurse include in the discharge teaching for a client who needs to perform the self-catheterization technique at home? -Catheterize every 4 to 6 hours. -Maintain sterile technique. -Use the Crede maneuver before catheterization. -Drink 500 mL of fluid within 2 hours of catheterization.

-Catheterize every 4 to 6 hours.

A client with a history of atrial fibrillation is admitted to the telemetry unit with sudden onset of shortness of breath. The nurse observes a new irregular heart rhythm and should perform which assessment at this time? -Check for a pulse deficit. -Palpate the apical impulse. -Inspect jugular vein pulse. -Examine for a carotid bruit.

-Check for a pulse deficit.

The nurse is caring for a client with non-Hodgkin's lymphoma who is receiving chemotherapy. Laboratory results reveal a platelet count of 10,000/mL. Which action should the nurse implement? -Encourage fluids to 3000 mL/day. -Check stools for occult blood. -Provide oral hygiene every 2 hours. -Check for fever every 4 hours.

-Check stools for occult blood.

Which finding should the nurse identify as an indication of carbon monoxide poisoning in a client who experienced a burn injury during a house fire? -Pulse oximetry reading of 80%. -Expiratory stridor and nasal flaring. -Cherry red color to the mucous membranes. -Presence of carbonaceous particles in sputum.

-Cherry red color to the mucous membranes.

A client who is admitted to the emergency department with a possible tension pneumothorax after a motor vehicle collision is having multiple diagnostic tests. Which finding requires immediate action by the nurse? -Serum amylase of 132 units/L. -Serum sodium of 134 mEq/L. -Chest x-ray indicating a mediastinal shift. -Abdominal x-ray with air noted throughout intestines.

-Chest x-ray indicating a mediastinal shift.

Which assessment finding is of greatest concern to the nurse who is caring for a client with stomatitis? -Cough brought on by swallowing. -Sore throat caused by speaking. -Painful and dry oral cavity. -Unintended weight loss.

-Cough brought on by swallowing.

A client has been told that there is cataract formation over his both eyes. Which finding should the nurse expect when assessing the client? -Decreased color perception. -Presence of floaters. -Loss of central vision. -Reduced peripheral vision.

-Decreased color perception.

The nurse is caring for a male client who had an inguinal herniorrhaphy 3 hours ago. The nurse determines the client's lower abdomen is distended and assesses dullness to percussion. Which is the priority nursing action? -Assessment of the client's vital signs. -Document the finding as the only action. -Determine the time the client last voided. -Insert a rectal tube for the passage of flatus.

-Determine the time the client last voided.

A client with a history of hypertension, myocardial infarction, and heart failure is admitted to the surgical intensive care unit after coronary artery bypass surgery graft (CABG). The nurse determines the client's serum potassium level is 4.5 mEq/L. Which action should the nurse implement? -Notify the healthcare provider. -Decrease the IV solution flow rate. -Document the finding as the only action. -Administer potassium replacement as prescribed.

-Document the finding as the only action.

When teaching a client with breast cancer about the prescribed radiation therapy for treatment, which information is important to include? -Dry, itchy skin changes may occur. -There is a possibility of long bone pain. -Permanent pigment changes to the breast may result. -A low-residue diet may be ordered to reduce the likelihood of diarrhea.

-Dry, itchy skin changes may occur.

After a liver biopsy is performed at the bedside, the nurse is assigned to care for the client. Which nursing intervention is most important for the nurse to implement? -Position the client on the left side with a pillow placed under the costal margin. -Assist the client with voiding immediately after the procedure. -Evaluate vital signs every 15 minutes x 2, then every 30 minutes x 4, then hourly x 4. -Ambulate the client 3 times in the first hour with a pillow held at the abdomen.

-Evaluate vital signs every 15 minutes x 2, then every 30 minutes x 4, then hourly x 4.

A client is admitted to the emergency department after being lost for four days while hiking in a national forest. Upon review of the laboratory results, the nurse determines the client's serum level for thyroid-stimulating hormone (TSH) is elevated. Which additional assessment should the nurse make? -Body mass index. -Skin elasticity and turgor. -Thought processes and speech. -Exposure to cold environmental temperatures.

-Exposure to cold environmental temperatures.

The nurse is caring for a client with end-stage liver disease who is being assessed for the presence of asterixis. To assess the client for asterixis, which position should the nurse ask the client to demonstrate? -Extend the left arm laterally with the left palm upward. -Extend the arm, dorsiflex the wrist, and extend the fingers. -Extend the arms and hold this position for 30 seconds. -Extend arms with both legs adducted to shoulder width.

-Extend the arm, dorsiflex the wrist, and extend the fingers.

A female client with type 2 diabetes mellitus reports dysuria. Which assessment finding is most important for the nurse to report to the healthcare provider? -Suprapublic pain and distention. -Bounding pulse at 100 beats/minute. -Fingerstick glucose of 300 mg/dL. -Small vesicular perineal lesions.

-Fingerstick glucose of 300 mg/dL.

A client who returns to the unit after having a percutaneous coronary intervention (PCI) with balloon angioplasty, complains of acute chest pain. Which action should the nurse implement next? -Inform the healthcare provider. -Obtain a 12-lead electrocardiogram. -Give a sublingual nitroglycerin tablet. -Administer prescribed analgesic.

-Give a sublingual nitroglycerin tablet.

A client in an ambulatory clinic describes awaking in the middle of the night with difficulty breathing and shortness of breath related to paroxysmal nocturnal dyspnea. Which underlying condition should the nurse identify in the client's history? -Chronic bronchitis. -Gastroesophageal reflux disease (GERD). -Heart failure (HF). -Chronic pancreatitis.

-Heart failure (HF).

Which sexually transmitted infection (STI) should the nurse include in a client's teaching plan about the risk for cervical cancer? -Neisseria gonorrhoea. -Chlamydia trachomatis. -Herpes simplex virus. -Human papillomavirus.

-Human papillomavirus.

A client with primary dysmenorrhea has several medications at home. She calls the clinic to ask the nurse which medication should she use for her pain. Which option should the nurse recommend as the first choice in the management of this client's pain? -Aspirin. -Codeine. -Ibuprofen. -Acetaminophen.

-Ibuprofen.

The nurse is caring for a client who returns to the unit following a colonoscopy. Which finding should the nurse report to the healthcare provider immediately? -Large amounts of expelled flatus with mucus. -Tympanic abdomen and hyperactive bowel sounds. -Increased abdominal pain with rebound tenderness. -Complaint of feeling weak with watery diarrheal stools.

-Increased abdominal pain with rebound tenderness.

The nurse is caring for a client after transurethral resection of the prostate (TURP) and determines the client's urinary catheter is not draining. What should the nurse implement? -Reposition the catheter drainage tubing. -Encourage the client to drink oral fluids. -Irrigate the catheter. -Change drainage unit tubing.

-Irrigate the catheter.

The healthcare provider prescribes a high-protein, high-fat, low-carbohydrate diet with limited fluids during meals for a client recovering from gastric surgery. The client asks the nurse what the purpose is for this type of diet. Which rationale should be included in the nurse's explanation to this client? -It is quickly digested. -It does not cause diarrhea. -It does not dilate the stomach. -It is slow to leave the stomach.

-It is slow to leave the stomach.

A client's prostate-specific antigen (PSA) exam result showed a PSA density of 0.13 ng/mL. Which conclusion regarding this lab data is accurate? -Probable prostatitis. -Low risk for prostate cancer. -The presence of cancer cells. -A biopsy of the prostate is indicated.

-Low risk for prostate cancer.

A client with osteoarthritis requests information from the nurse about which type of exercise regimen would be most beneficial for him. The nurse should communicate which information? -Low-impact exercise, walking, swimming, and water aerobics. -Repetitive strength-building exercises with weights or resistance bands. -Circuit training alternating with frequent rest periods. -High-impact aerobic exercise.

-Low-impact exercise, walking, swimming, and water aerobics.

The nurse is providing instructions about log rolling to a client who returns to the postoperative unit after a lumbar laminectomy. Which explanation should the nurse give the client about this technique? -Helps to minimize pain and anxiety. -Maintains correct spinal alignment to protect the surgical area. -Prevents dizziness while stabilizing the spine. -Allows the nurse to move the client freely without assistance.

-Maintains correct spinal alignment to protect the surgical area.

An 85-year-old male client comes to the clinic for his annual physical exam and renewal of antihypertensive medication prescriptions. The client's radial pulse rate is 104 beats/minute. Which additional assessment should the nurse complete? -Palpate the pedal pulse volume. -Count the brachial pulse rate. -Measure the blood pressure. -Assess for a carotid bruit.

-Measure the blood pressure.

Which preexisting diagnosis places a client at the greatest risk of developing superior vena cava syndrome? -Carotid stenosis. -Steatosis hepatitis. -Metastatic cancer. -Clavicular fracture.

-Metastatic cancer.

The nurse is caring for a client scheduled to undergo the insertion of a percutaneous endoscopic gastrostomy (PEG) tube. The client asks the nurse to explain how a PEG tube differs from a gastrostomy tube (GT). Which explanation best describes how they are different? -Method of insertion. -Location of the tubes. -Diameter of the tubes. -Procedure for feedings.

-Method of insertion.

A client is admitted for complaints of chest pain and aching for the past 4 days. The results for serum (CK-MB) and troponin levels. Which rationale should the nurse use? Serum myoglobin levels are needed to confirm myocardial damage. The most reliable indicator of myocardial necrosis is serum CK-MB. Serum cardiac markers are inconclusive in determining myocardial injury after waiting several days. Myocardial damage that occurred several days earlier is best validated by serum troponin levels.

-Myocardial damage that occurred several days earlier is best validated by serum troponin levels.

A male client with sickle cell anemia, who has been hospitalized for another health problem, tells the nurse he has had an erection for over 4 hours. Which action should the nurse implement first? -Notify the client's healthcare provider. -Document the finding in the client record. -Prepare a warm enema solution for rectal instillation. -Obtain a large bore needle for aspiration of the corpora cavernosa

-Notify the client's healthcare provider.

During the assessment of a client who is 24 hours posthemicolectomy with a temporary colostomy, the nurse determines that the client's stoma is dry and dark red in color. Which action should the nurse implement? -Notify the surgeon. -Document the assessment. -Secure a colostomy pouch over the stoma. -Place petrolatum gauze dressing over the stoma.

-Notify the surgeon.

The nurse is assessing a client with a cuffed tracheostomy tube in place who is breathing spontaneously. To evaluate if the client can tolerate cuff deflation to promote speaking and swallowing, which action should the nurse implement? -Ask the client to try to speak. -Assess for respiratory distress. -Auscultate for pulmonary crackles after the client drinks a small amount of clear water. -Observe the client for coughing colored sputum after drinking a small amount of colored water.

-Observe the client for coughing colored sputum after drinking a small amount of colored water.

A client with a recent history of blood in his stools is scheduled for a proctoscopy/sigmoidoscopy. The nurse should implement which protocols to prepare the client for this procedure? (Select all that apply.) -Obtain consent for the procedure. -Initiate preoperative sedation. -Begin fast the morning of the procedure. -Administer an enema before the procedure. -Provide a clear-liquid diet 48 hours before the procedure.

-Obtain consent for the procedure. -Begin fast the morning of the procedure. -Administer an enema before the procedure. -Provide a clear-liquid diet 48 hours before the procedure.

A 40-year-old female client has a history of smoking. Which finding should the nurse identify as a risk factor for myocardial infarction? -Oral contraceptives. -Senile osteopenia. -Levothyroxine therapy. -Pernicious anemia.

-Oral contraceptives.

A nurse is preparing a teaching plan for a client who is postmenopausal. Which measure is most important for the nurse to include to prevent osteoporosis? -Take a multivitamin daily. -Use only low fat milk products. -Perform weight resistance exercises. -Bicycle for at least 3 miles every day.

-Perform weight resistance exercises.

The nurse is caring for a client who has a closed head injury from a motor vehicle collision. Which assessment finding could potentially indicate diabetes insipidus (DI)? -High fever. -Low blood pressure. -Muscle rigidity. -Polydipsia.

-Polydipsia.

The nurse is teaching a client who is newly diagnosed with emphysema on how to perform pursed lip breathing. What is the primary reason for teaching the client this method of breathing? -Decreases respiratory rate. -Increases O2 saturation throughout the body. -Conserves energy while ambulating. -Promotes CO2 elimination.

-Promotes CO2 elimination.

The nurse is evaluating a client who presents with symptoms of viral gastroenteritis. Which assessment finding should the nurse report to the healthcare provider? -Dry mucous membranes and lips. -Rebound abdominal tenderness over the right lower quadrant. -Dizziness when client ambulates from a sitting position. -Poor skin turgor over the client's wrist.

-Rebound abdominal tenderness over the right lower quadrant.

The nurse is providing postoperative instructions for a female client after a mastectomy. Which information should the nurse include in the teaching plan? (Select all that apply.) -Empty surgical drains once a week using procedure gloves. -Report inflammation of the incision site or the affected arm. -Wear clothing with snug sleeves over the arm on the operative side. -Avoid lifting more than 4.5 kg (10 pounds) or reaching above her head.

-Report inflammation of the incision site or the affected arm. -Avoid lifting more than 4.5 kg (10 pounds) or reaching above her head.

The nurse is caring for a client with human immunodeficiency virus (HIV) infection who develops Mycobacterium avium complex (MAC). Which is the most significant desired outcome for this client? -Free from injury of drug side effects. -Return to pre-illness weight. -Adequate oxygenation. -Maintenance of intact perineal skin.

-Return to pre-illness weight.

The nurse is preparing discharge instructions for a client who is going home with a surgical wound on the coccyx that is healing by secondary intention. Which is the priority nursing problem that should guide the discharge instruction plan? -Acute pain. -Risk for infection. -Disturbed body image. -Risk for deficient fluid volume.

-Risk for infection.

A client is admitted to the hospital with a traumatic brain injury after his head violently struck a brick wall during a gang fight. Which finding is most important for the nurse to assess further? -A scalp laceration oozing blood. -Serosanguineous nasal drainage. -Headache rated "10" on a 0 to 10 scale. -Dizziness, nausea, and transient confusion.

-Serosanguineous nasal drainage.

The nurse is caring for a client who is admitted with a hemorrhagic stroke. Which nursing action should be included in the plan of care? -Perform active range of motion three times daily. -Monitor for Battle's sign every four hours. -Teach measures to avoid the Valsalva maneuver. -Maintain the head of bed in a flat position.

-Teach measures to avoid the Valsalva maneuver.

The nurse is caring for a client with tuberculosis who is taking a combination drug regimen. The client complains about taking "so many pills." Which information should the nurse provide to the client? -The development of resistant strains of TB is decreased with a combination -Compliance with the medication regimen is challenging but should be maintained. -Side effects are minimized with the use of a single medication -The treatment time is decreased from 6 months to 3 months with this

-The development of resistant strains of TB is decreased with a combination

A client, who speaks very little English, is being discharged following surgery. Which nurse should the nurse manager assign to provide the discharge instructions for the client? -A graduate registered nurse (RN) with three weeks of experience. -The registered nurse (RN) case manager for the unit with 1 year's experience. -A "floating" registered nurse (RN) with five years of nursing experience. -A Korean-American practical nurse (PN) with six years of nursing experience.

-The registered nurse (RN) case manager for the unit with 1 year's experience.

A client asks the nurse which possible treatments might be used for their tumor. How should the nurse reply? -Radiation is never used on tumors. -Chemotherapy is mandated for all types of cancer. -Surgery is the only cancer treatment needed for tumors. -The three hallmark treatments include surgery, radiation, and chemotherapy.

-The three hallmark treatments include surgery, radiation, and chemotherapy.

A client with Meniere's disease is incapacitated by vertigo and is lying in bed grasping the side rails and staring at the television. Which nursing intervention should the nurse implement? -Encourage fluids to 3000 mL per day. -Change the client's position every two hours. -Keep the head of the bed elevated by 30 degrees. -Turn off the television and darken the room.

-Turn off the television and darken the room.

The nurse is assessing a client admitted from the emergency room with gastrointestinal bleeding related to peptic ulcer disease (PUD). Which physiological factors can produce ulceration? (Select all that apply.) -Vagal stimulation. -An increased level of stress. -Decreased duodenal inhibition. -Hypersecretion of hydrochloric acid. -An increased number of parietal cells.

-Vagal stimulation. -Decreased duodenal inhibition. -Hypersecretion of hydrochloric acid. -An increased number of parietal cells.

The nurse assesses a long-term resident of a nursing home and finds the client has a fungal infection (candidiasis) beneath both breasts. To prevent hospital-associated infection, which protocol should the nurse review with the rest of the staff? -Follow contact isolation procedures. -Wash hands after caring for the client. -Wear gloves when providing personal care. -Restrict pregnant staff or visitors into the room.

-Wash hands after caring for the client.

The nurse recognizes which client group is at the greatest risk for developing a urinary tract infection (UTI)? (Rank from highest risk to lowest risk.) -older females -school-age females -older males -adolescent males

-older females -school-age females -older males -adolescent males

Which findings are within the expected parameters of a normal urinalysis for an older adult? (Select all that apply.) -pH 6. -Nitrate small. -Protein small. -Sugar negative. -Bilirubin negative. -Specific gravity 1.015.

-pH 6. -Sugar negative. -Bilirubin negative. -Specific gravity 1.015.